Community Acquired Acute Gastrointestinal Infection ( including Food Poisoning ) in Adults Seen in Accident and Emergency and/or Requiring Hospital Admission - Guideline for the Management of
|Last review: 21/08/2017|
|Next review: 01/08/2020|
|Approved By: Improving Antimicrobial Prescribing Group|
|Copyright© Leeds Teaching Hospitals NHS Trust 2017|
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
Guideline for the Management of Community Acquired Acute Gastrointestinal Infection (including Food Poisoning) in Adults Seen in Accident and Emergency and/or Requiring Hospital Admission
Community Acquired Acute Gastrointestinal Infection ( including Food Poisoning ) in Adults Seen in Accident and Emergency and/or Requiring Hospital Admission
Background and history:
Empirical (initial) antimicrobial treatment:
Table 1: summary of pathogen-specific antimicrobial treatment:
* Doses assume normal renal function. If renal impairment present consult pharmacy.
Referral to Public Health England:
When taking a history from a patient with gastroenteritis it is important to cover the following elements 7:
It is important to identify patients who are immune-compromised as they are at increased risk of an adverse outcome, and may benefit from treatment 8.
A review of the patient’s medication may identify drugs whose absorption can be affected by severe gastroenteritis (e.g. warfarin) and those that can exacerbate dehydration/renal failure, which may therefore need omitting temporarily (e.g. diuretics, angiotensin-converting enzyme inhibitors).
An attempt should also be made to try and identify the potential source of the infection. It is important to ask about 9:
It is important to ascertain a patient’s occupation as it may influence the public health advice they require, e.g. for food-handlers or health/social care workers.
A full physical examination should be performed and must include an assessment of the following features:
The symptoms and sings of acute gastroenteritis are not specific 6. They may be a presenting feature of numerous other conditions. Therefore, do not forget to consider alternative diagnoses as appropriate to the clinical picture. These may include:
Haemolytic-uraemic syndrome (HUS):
If HUS is suspected then request a blood film, perform urinalysis and a haemolysis screen (Evidence level D).
Take blood cultures if the patient has features of sepsis or if enteric fever (typhoid or paratyphoid) is suspected. See LTHT guideline for blood culture sampling
Consider an abdominal radiograph if there is abdominal pain/distension. An erect chest radiograph should be performed if there is evidence of peritonism (Evidence level C).
Given the high prevalence of enteric viruses in a recent UK survey of the causes of community-acquired gastroenteritis 10 stool (or vomit) samples should be sent for enteric virus PCR in the following groups: patients who are admitted to hospital, the immunecompromised and cases that may be part of an outbreak (Evidence level D).
Testing for Clostridium difficile toxin is routinely undertaken in patients over 65 years old but should be requested in any patient with risk factors for CDI (see history section; Evidence level C).
If there is a history of recent travel, the patient is immunocompromised, or symptoms have been present for more than 2 weeks, three stool samples should be sent for ova, cysts and parasites (OCP; Evidence level C).
Consider investigations relevant to other conditions in the differential diagnosis, as required.
Anti-diarrhoeals (e.g. loperamide, co-phenotrope and codeine):
|Empirical Antimicrobial Treatment|
A number of randomized controlled trials have compared antibiotic therapy with placebo in the management of community-acquired acute gastroenteritis 15-17. Whilst they have shown a reduction in the duration of symptoms of between 1-2 days this has to be balanced against the potential negative consequences of empiric therapy in an illness that is self-limiting and without long-term consequences in most adults. Antimicrobials can be associated with the following unwanted effects: increased excretion of salmonellae 18, adverse reactions, harmful eradication of normal bowel flora (which may predispose to CDI), the induction of verotoxin production (increasing the risk of HUS) 19 and the emergence of antibiotic-resistant pathogens 15, 17. For these reasons the use of antimicrobial therapy for the empirical treatment of acute gastoenteritis is NOT recommended in most patients (Evidence level C). This policy is in line with the recommendation of published guidelines 7-9, 12.
However, if a patient has RED FLAG features of sepsis/shock, empirical antibiotics should be started promptly. For information on the features of sepsis click here.
Antimicrobials should also be started in patients who are immunocompromised.
They can be considered in those who have severe acute symptoms (even if they do not have evidence of sepsis/shock).
Despite rising rates of quinolone resistance in Salmonella and Campylobacter species, published guidelines still recommend one of these agents, usually Ciprofloxacin 6-8,11 (Evidence level C). This is, however, no longer the case for Salmonella Typhi/Paratyphi (the causative agents of enteric fever). Cases of suspected enteric fever should be discussed URGENTLY with Infectious Diseases. If the patient has a life-threatening infection or is immunocompromised several authors advise adding a macrolide to treat quinolone-resistant Campylobacter species 11, 12 (Evidence level C).
Summary of empirical antibiotic recommendations for severe acute gastroenteritis (note antibiotics are NOT recommended in the majority of cases, ONLY if patients fulfil the criteria outlined above):
N.B. If there is clinical/laboratory evidence of HUS antibiotics should be avoided as they may worsen the condition. These cases should be discussed with Microbiology/Infectious Diseases.
It is important to remember that symptoms of gastroenteritis can occur in sepsis due to other causes. If the clinical presentation suggests that an alternative aetiology, other than acute gastroenteritis, is more likely, then refer to the LTHT sepsis guideline for empirical antibiotic advice.
N.B. All doses assume normal renal function. If patient has renal impairment consult a pharmacist for dosing advice.
|Directed Antimicrobial Treatment (when microbiology results are known)|
Note that the majority of patients without sepsis will not require treatment, even when the causative pathogen is identified. See organism-specific notes below for full recommendations.
All cases will still require notification to the HPU (see below).
Salmonella (not including enteric fever):
E.coli O157 (and other verotoxin producing strains):
Table 3: Summary table of recommended antibiotics against specific enteric pathogens:
* Doses assume normal renal function. If renal impairment present consult pharmacy.
Ciprofloxacin (electronic Medicines Compendium information on) Ciprofloxacin 400mg 12-h
†Certain patients, e.g. immunocompromised, may need longer duration. Discuss with Microbiology/Infectious Diseases.
Notification of cases to Public Health England:
Cases of food poisoning, HUS, infectious bloody diarrhoea, and enteric fever (typhoid or paratyphoid) should be notified urgently (within 24 hours) to the West Yorkshire Health Protection Team, either by telephone or by a notification form. If a case involves a food handler this should also prompt urgent notification. The contact number for the West Yorkshire Health Protection Team from 9am to 5pm Monday-Friday is 0113 386 0300. Outside these hours, the Out-of-hours advice service can be contacted on 0114 304 9843.
|Duration of Treatment|
When no causative pathogen is identified empirical treatment should be given for 5 days (Evidence level D).
For specific organisms see table in Directed Antimicrobial Treatment section.
|Switch to oral agent(s)|
If intravenous therapy is required it should be switched to the oral route as soon as the patient fulfils the criteria set out in the LTHT “intravenous to oral switch” guideline. Oral doses are as follows (NB assuming normal renal function):
|In case of treatment failure Discuss with Microbiology or Infectious Diseases.|
Acute gastroenteritis (including food poisoning) in adult patients
|Target patient group:||Adults patients seen in Accident and Emergency and all those admitted to hospital|
|Target professional group(s):||Pharmacists
Secondary Care Doctors
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A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. Leeds consensus. (where no national guidance exists or there is wide disagreement with a level C recommendation or where national guidance documents contradict each other)
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